Medical coverage information



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How to use Apple Health (Medicaid) services and private health insurance to receive health care

Q: If I have private insurance, will Apple Health still help me?

A: Yes. Having Apple Health along with your private insurance really helps. As long as you qualify for Apple Health, we may pay co-pays, deductibles and services your insurance does not cover.

Q: If I have both private insurance and Apple Health what do I tell my doctors or other medical providers?

A: It is important that you go to providers who will take both your private insurance and Apple Health Services Card (also called ProviderOne services card) and/or your Apple Health plan card.

When you go to your doctor or other medical provider(s), show all your cards including the private health insurance card, your Apple Health services card and health plan card, if you are enrolled in a managed care plan.

Q: What should I do if my doctors or other providers say they won’t take my private insurance or Services Card?

A: You should look for providers who will accept both your Apple Health and private insurance. You may need to call your insurance company for assistance in locating providers in your area;

• If your provider doesn’t accept Apple Health (including Apple Health contracted managed care plans), you will want to find a provider who does, otherwise you may be responsible for any

co-pays or deductibles.

• If your provider accepts Apple Health, but is not part of the managed care plan you are enrolled in:

o The provider can choose to bill the managed care plan,

o You may need to seek a different provider; or

o You can request to change your managed care plan to a plan your provider accepts.

Q: What happens if my private insurance doesn’t cover a service?

A: Your doctor will bill your private insurance first. If the service isn’t covered by your insurance but is covered by Apple Health, they will bill Apple Health or the managed care plan for payment. To make sure there are no problems, always take your Apple Health Services Card and your health plan card.

Q: What do I need to do to have you pay my health insurance premium?

A: Call us. We will need information about your health insurance, your premium amount, when it is due and whether

you or your employer pays the premium. Once we have this information we will let you know if we can pay your premium.

Q: Will I be asked to pay the difference between what Apple Health pays and what my provider bills?

A: No. When doctors and other providers work with Apple Health, they agree to take what Apple Health pays and not bill you for any difference. If you receive a bill, call us immediately. You can't be billed for an Apple Health covered service.

Q: What if my private insurance ends or changes?

A: It's important to call your managed care plan and report any changes to your private insurance coverage. They will update your file and you will continue to receive medical care through Apple Health as long as you qualify.

Q: If I have long-term care (LTC) insurance, will Apple Health still help me?

A: Yes. Apple Health can help pay your LTC costs when you are in your own home, an assisted living facility, an adult family home, or a nursing facility if your LTC insurance will not pay for all of the costs. If the insurance pays you directly you must send the insurance checks to the facility providing your care.

Q: Why should I keep my LTC insurance if I qualify for Apple Health?

A: There is no guarantee that you will always qualify for Apple Health. You may receive additional sources of income or assets that could cause your eligibility to be terminated or the legislature might reduce funding for some programs. If you cancel your LTC insurance you may not be able to get it back. LTC insurance benefits will also reduce any obligations against your estate when you pass away.

HCA 14-194 (3/17)

Q: Why do you need a Social Security Number?

A: These federal laws say that anyone applying for Medicaid benefits must provide a Social Security Number (42 USC 132b-7(a), 42 CFR 435.910, 42 CFR 435.920, and 42 CFR 457.340(b).). These regulations help

us make sure that we give you the correct amount of benefits and to recover money if we have overpaid benefits.

Q: What if I have other questions?

A: If you have questions about your private health insurance, call your plan directly. For additional assistance with using your Services Card with your private insurance, call us at the number below.

Coordination of Benefits TOLL FREE 1-800-562-3022

Monday - Friday: 7:00a.m. – 5:00 p.m.

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Medical Coverage Information

IMPORTANT INFORMATION: The purpose of this form is to find out if you have private health insurance. You can have private insurance and still be covered by Apple Health (Medicaid). When you have completed this form, please return it in the attached envelope to Health Care Authority, PO Box 45565, Olympia, WA 98504-5565. If you have questions about this form, please call 1-800-562-3022

Client Name Date Telephone Number Date of Birth ACES Client ID#

A. Do you have medical insurance coverage (including Military benefits)? Yes No

B. Do you have dental insurance coverage? Yes No

C. Have you had medical or dental insurance in the past 12 months? Yes No

D. Do you have Long Term Care (LTC) insurance? Yes No? If yes, please indicate which coverage you have:

Nursing Home Assisted Living Adult Family Home In-Home Care Other:

If you selected Yes to any of the items above, please complete the following for each insurance policy (Please use additional pages if needed):

List who is covered by this policy (use additional paper if needed)

1. Type of Policy: Medical Dental Long Term Care

Insurance Name Phone Number 1.

Name Date of Birth

Address (as listed on your card) 2.

Policy Number Policy Begin Date Policy End Date 3.

Subscriber Name Subscriber Date of Birth Subscriber SSN 4.

Employer Union Name and Local Number, If Applicable 5.

2. Type of Policy: Medical Dental Long Term Care

List who is covered by this policy (use additional paper if needed)

Name Date of Birth

Insurance Name Phone Number 1.

Address (as listed on your card) 2.

Policy Number Policy Begin Date Policy End Date 3.

Subscriber Name Subscriber Date of Birth Subscriber SSN 4.

Employer Union Name and Local Number, If Applicable 5.

3. Type of Policy: Medical Dental Long Term Care

List who is covered by this policy (use additional paper if needed)

Name Date of Birth

Insurance Name Phone Number 1.

Address (as listed on your card) 2.

Policy Number Policy Begin Date Policy End Date 3.

Subscriber Name Subscriber Date of Birth Subscriber SSN 4.

Employer Union Name and Local Number, If Applicable 5.

Premium Payment Program

If you are receiving Apple Health coverage, have private health insurance and would like assistance with your health insurance premiums, please call 1-800-562-3022 x15473 or complete form, “Application for HCA Premium Payment Program” (HCA 13-705) to see if you qualify. You can find the form online at hca.assets/free-or-low-cost/13-705.pdf

Accident or Injury Information

Have you or the person you are applying for had an accident requiring medical care within the last 3 years? Yes No

Was the accident due to:

Date of Accident

Automobile On the Job (L&I) Malpractice Personal Injury at a Business or Another’s Home A Faulty product Criminal Activity Other:

If you checked automobile, please complete the rest of this section

Location of Accident (Street/Intersection, City, County, and State)

| Is an insurance company involved? Yes No |

|Name of the Insured | | | | |

|Insurance Name | | | | |Insurance Address |

|Claim Number | | | | |Policy Number |

|Adjuster Name | | | | |Adjuster Phone Number |

Name of Person(s) Hurt in Accident (Use additional paper if needed)

1.

Injuries

2.

3.

4.

5.

Is an attorney involved? Yes No

Attorney Name Attorney Phone Number Attorney Address

I hereby authorize the release of any information necessary regarding coverage of any insurance policy for which I am the beneficiary or the person obtaining coverage, to the Health Care Authority for the purpose of coordination of health/medical benefits. (WAC 182-503-0540)

Signature Date

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